From the Guidelines
The next step for a 28-year-old male with an atraumatic sacrum fracture identified on MRI should be a comprehensive workup to determine the underlying cause, as this is not typical in a young male without trauma. I recommend obtaining laboratory studies including complete blood count, comprehensive metabolic panel, calcium, phosphorus, parathyroid hormone, 25-hydroxyvitamin D, and bone turnover markers 1. Additionally, a dual-energy X-ray absorptiometry (DEXA) scan should be performed to assess bone mineral density. For pain management, start with acetaminophen 1000mg every 6 hours and/or NSAIDs like ibuprofen 600mg every 6 hours as needed, unless contraindicated. Physical therapy focusing on core strengthening and proper body mechanics should be initiated. The patient should be referred to an endocrinologist or rheumatologist to evaluate for potential metabolic bone disease, osteoporosis, or other systemic conditions that could cause bone fragility.
This approach is necessary because atraumatic fractures in young adults often indicate an underlying pathology such as osteoporosis, malignancy, infection, or metabolic disorders that require specific treatment beyond fracture management 1. The diagnosis of stress fracture is made, and additional imaging is typically not needed, but in this case, since the patient is young and the fracture is atraumatic, further evaluation is necessary to rule out underlying conditions 1.
Some key points to consider in the management of this patient include:
- The patient's age and lack of trauma make an underlying condition more likely
- The need for a comprehensive workup to determine the underlying cause of the fracture
- The importance of assessing bone mineral density and evaluating for metabolic bone disease
- The role of physical therapy in promoting proper body mechanics and core strengthening
- The potential need for referral to a specialist, such as an endocrinologist or rheumatologist, to evaluate for underlying conditions.
It is also important to note that the patient's symptoms and medical history should be taken into account when determining the best course of action, and that the patient should be closely monitored for any changes in their condition 1.
From the Research
Diagnosis and Treatment of Sacral Fractures
- Sacral fractures can be caused by traumatic insults or osteoporosis, and are often underdiagnosed 2.
- The use of MRI can help identify sacral fractures, especially in cases where the fracture is not visible on X-ray or CT scans 3.
- A study found that MRI showed a more complex fracture pattern compared to CT in 65% of cases, and detected all fractures 3.
- The sensitivity of MRI in detecting sacral insufficiency fractures is higher than that of X-ray and CT 3.
Management of Sacral Fractures
- The management of sacral fractures depends on the type and severity of the fracture, as well as the patient's overall health 4, 5.
- Non-surgical management may be appropriate for some cases, while others may require surgical intervention 5.
- The use of biochemical parameters such as alkaline phosphatase and bone-specific alkaline phosphatase can help monitor the healing process of sacral fractures 6.
- A study found that monitoring changes in these biochemical parameters can allow for early detection of fracture healing rates 6.
Specific Considerations for Atraumatic Sacrum Fracture
- Atraumatic sacrum fractures, such as those caused by osteoporosis, may require a different approach to management than traumatic fractures 2, 5.
- The use of MRI to evaluate the lumbar spine and sacrum can help identify additional pathologies and improve fracture detection and classification 3.
- A study suggested that performing MRI of the lumbar spine including the sacrum with coronal STIR sequence may improve fracture detection and recognition of concomitant pathologies in elderly patients with suddenly increasing low back pain 3.